CREDIT CARD AUTHORIZATION FORM

Your Organization Information

Federal Tax ID#: Federal Tax ID#: 46-4457008

I hereby authorize the followig credit card for a one-time charge of:	$.00
Enter the reason for this charge:

Name on card:
Card number:
Expiration date:	/
Security Code:
	The security code is the 4 digit number on the front of Amex cards and the 3 digit number on the back of MasterCard, Visa, and Discover cards.
Card Billing Address:
Card Billing Zip Code:

By signing below, you hereby authorize the above credit card for a one-time charge for the indicated amount.


Authorized Signature	Date